Provider Demographics
NPI:1760754667
Name:GOODRUM, NADINE DENISE
Entity Type:Individual
Prefix:
First Name:NADINE
Middle Name:DENISE
Last Name:GOODRUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12429 PHILLIPS AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108-4045
Mailing Address - Country:US
Mailing Address - Phone:216-466-4971
Mailing Address - Fax:
Practice Address - Street 1:12429 PHILLIPS AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108-4045
Practice Address - Country:US
Practice Address - Phone:216-466-4971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide